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Day - 08 Hour (United States of America)

Why work at Stanford Medicine | Stanford Health Care (SHC)?

Here is your opportunity to mentor and support the UM professionals.

Here is your opportunity to put your UM experience and management skills to drive the continuity of care in this rewarding career.

Benefits begin the first day of the month following employment eligibility.

Our core benefits include medical insurance, dental insurance, vision insurance, an employee assistance program, savings and spending accounts, disability, life and accident insurance, and COBRA. For medical insurance, you have the choice of three generous health plans through Stanford Health Care Alliance, Aetna, or Kaiser Permanente. Each plan includes 100% coverage for preventive care, telemedicine through Teledoc, prescription drug coverage, and behavioral health coverage. Additional incentives exist for healthy choices. And so much more – generous leave & time off, Wellness Program, special programs, educational assistance, and adoption assistance!

This is an onsite Stanford Health Care job.

A Brief Overview

The Dir-Utilization Management (UM) leads and shapes the UM Strategy, while providing management oversight in implementing, directing, and monitoring the SHC UM Department functions including prior authorizations, utilizing standardized criteria to determine medical necessity, appropriate admission status and continued stay review, retrospective review of care, medical claims review, addressing denials/appeals and grievances effectively and timely, and compliance with payer and regulatory requirements. Directs the UM Department, acts as a subject matter expert, and provides advice and guidance on the Department's functions and overall business operations. Directs, manages, and supervises UM Department staff

Locations

Stanford Health Care (Palo Alto, CA; onsite)

What you will do

• Leads the development of UM strategy by leveraging the use of data/analytics to inform and technology solutions to streamline operational efficiencies while also building a cost-benefit methodology to rationalize decisions on UM reviews to be performed based upon staffing costs, productivity, and projected medical cost savings.

• Identifies opportunities to create efficiencies in the UM program and activities, incorporating innovative approaches and solutions, and leading process redesign work necessary to implement improvements.

• Directs the utilization management, concurrent review, prior authorizations medical claims review, appeals and grievances functions.

• Establishes and measures productivity metrics in order to support workforce planning methodology and rationalization of services to perform UM reviews.

• Develops and maintains protocols for Treatment Authorization Request (TAR) authorization criteria.

• Ensures contractual turnaround times are met by staff, and performs duties associated with Prior Authorization.

• Reviews and reports out on Utilization Review (UR) trending.

• Ensures quality of services through UR, review of medical records and provider education, while identifying training opportunities and trends.

• Designs, develops, implements, and maintains programs, policies, and procedures in order to meet regulatory, contractual, accreditation, and performance standards.

• Evaluates and oversees the implementation recommendations on program changes relative to covered services.

• Maintains knowledge of the UM software program functionality and leads the clinical team responsible for advising on replacement, upgrades, and user testing.

• Advises and collaborates with the UM/CM Medical Director on strategic issues involving Utilization Management Department programs.

• Collaborates with Physician Advisory Services to identify denial root causes and facilitates improvement initiatives and education to address causes.

• Develops and maintains collaborative working relationships with payers.

• Collaborates with Care Coordination, Clinical Documentation Improvement, Revenue Cycle, providers, and professional services to promote appropriate use of resources.

• Maintains knowledge of regulatory and accreditation agencies and related requirements pertinent to utilization management.

• Oversees UM Department preparations and responses to regulatory audits and the construction of corrective action plans.

• Participates in regulatory audits related to all aspects of utilization management.

• Tracks, analyzes, and develops strategies to address outlier performance of utilization metrics and reporting on metrics at a regular cadence.

• Conducts UM training for providers and care team members as needed.

• Ensures the Utilization Management Department goals and activities are in alignment with the organizations strategic and operational objectives.

• Develops performance measures related to strategic goals and new projects and presents to staff and leadership meetings.

• Prepares narrative and reports and makes presentations for Utilization Management Committee and other meetings as needed.

• Develops and manages the Utilization Management Department operations and budget.

• Attends and participates in internal and external meetings.

• Collaborates with the UM/CM Medical Director team on complex cases.

• Ensures Utilization Management staff maintains up-to-date knowledge, skills, and abilities related to the administration of assigned responsibilities and functions.

• Identifies, oversees, and assists with objectives, priorities, assignments, and tasks.

• Provides mentoring, coaching, and development and growth opportunities for manager and staff.

• Evaluates employee performance, provides feedback to staff, and counsels or disciplines staff when performance issues arise.

• Performs other duties as assigned.

Education Qualifications

• Master’s degree in nursing (MSN)

• Current unrestricted license as a Registered Nurse issued by the state of California.

• National certification of any of the following: CCCM, ACM required within 2 years upon hire.

Experience Qualifications

• Minimum of five (5) years of utilization management experience

• Five (5) years of progressively responsible management experience

Required Knowledge, Skills and Abilities

• Extensive operational experience in the principles and practices of utilization management, managed care, program planning, implementation, staff development and needs assessment.

• Comprehensive knowledge of financial management that includes revenue cycle, DRG reimbursement, coding process for inpatient and outpatient services, Medicaid, Medicare, commercial admission and review requirements and related regulations.

• Thorough knowledge of the use of InterQual or MCG Care Guidelines for medical necessity coverage determinations.

• Thorough knowledge of UM documentation requirements necessary to satisfy regulatory audits.

• Working knowledge of UM/CM software systems as applicable to clinical care.

• Working knowledge of and proficiency with Windows based PC systems and Microsoft Word, Excel, Outlook, and PowerPoint.

• Knowledge of healthcare regulatory processes.

• Knowledge of state and federal legislative processes.

• Ability to direct, manage, supervise, mentor, train and evaluate the work of staff.

• Ability to provide leadership, facilitate meetings, and partner with and guide managers and employees in the resolution of issues.

• Ability to develop, plan, organize and direct programs and activities that are complex in nature and regional in scope.

• Ability to identify, evaluate, and implement innovations and solutions to optimize, enhance and expand UM programs and activities.

• Ability to act as a technical resource and explain complex laws, regulations, processes, and programs related to area of responsibility.

• Ability to evaluate medical records and other health care data.

• Ability to demonstrate strong analytical skills, accurately collect, manage, and analyze data, identify issues, offer recommendations and potential consequences, and mitigate risk.

• Ability to identify and resolve problems in a timely manner.

Licenses and Certifications

• ACM

• CA Registered Nurse - Valid license as a Registered Nurse issued by the California Board of Registered Nursing (BRN). Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.

These principles apply to ALL employees:

SHC Commitment to Providing an Exceptional Patient & Family Experience

Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery.

You will do this by executing against our three experience pillars, from the patient and family’s perspective:

• Know Me: Anticipate my needs and status to deliver effective care

• Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health

• Coordinate for Me: Own the complexity of my care through coordination

Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.

Base Pay Scale: Generally starting at $94.28 - $124.90 per hour

The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.

At Stanford Health Care, we seek to provide patients with the very best in diagnosis and treatment, with outstanding quality, compassion and coordination. With an unmatched track record of scientific discovery, technological innovation and translational medicine, Stanford Medicine physicians are pioneering leading edge therapies today that will change the way health care is delivered tomorrow.

As part of our spirit of discovery, we also leverage our deep relationships with luminary Silicon Valley companies to develop new ways to deliver preeminent patient care.

Learn about our awards (https://stanfordhealthcare.org/about-us/awards.html) and significant events (https://stanfordhealthcare.org/about-us/our-history.html) .